Failure to Provide Behavioral Health Services and Accurate PASRR Screening
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident with multiple serious mental illness diagnoses, including schizophrenia, psychosis, and anxiety disorder. Upon admission, the resident's records indicated these diagnoses and active prescriptions for psychotropic medications such as lorazepam and chlordiazepoxide. However, the Level I PASRR screening completed for the resident did not document these serious mental illnesses or the use of psychotropic medications, resulting in a determination that a Level II Mental Health Evaluation was not required. Further review revealed that the resident did not have individualized care plans addressing the diagnoses of schizophrenia, psychosis, or anxiety disorder, nor were there care plans for the administration of psychotropic medications. The facility also lacked orders for monitoring the behavioral manifestations associated with these diagnoses while administering the medications. The DON confirmed that behavioral monitoring and care plans were absent, despite facility policy requiring individualized care plans and ongoing behavioral monitoring for residents receiving psychotropic medications. Facility policies reviewed indicated that residents with behavioral health needs and those on psychotropic medications should have individualized care plans, including non-drug interventions and regular monitoring of behaviors. The failure to accurately complete the PASRR, develop and implement appropriate care plans, and monitor behavioral manifestations while administering psychotropic medications constituted deficient practices in providing necessary behavioral health care and services.